| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2740 |
Crown - porcelain/ceramic |
59 |
26 |
$28K |
| D9430 |
|
873 |
842 |
$28K |
| D0120 |
Periodic oral evaluation - established patient |
536 |
534 |
$25K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,895 |
1,193 |
$24K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
302 |
301 |
$20K |
| D1110 |
Prophylaxis - adult |
238 |
237 |
$20K |
| D4910 |
|
220 |
220 |
$16K |
| D1120 |
Prophylaxis - child |
400 |
395 |
$13K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
24 |
12 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
872 |
796 |
$10K |
| D4341 |
|
135 |
37 |
$9K |
| D0210 |
Intraoral - complete series of radiographic images |
168 |
168 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
143 |
44 |
$7K |
| D2954 |
|
25 |
14 |
$3K |
| D0274 |
Bitewings - four radiographic images |
115 |
115 |
$2K |